Exotic arteriovenous fistulas for hemodialysis

Prosthetic brachial artery-external jugular vein arteriovenous grafts as a novel option for hemodialysis access: A case report

Following the exhaustion of all conventional hemodialysis access options in the upper extremities, a prosthetic arteriovenous loop was performed between the brachial artery (BA) and the external jugular vein (EJV) as a novel access option for hemodialysis in the present case report. During the procedure, a polytetrafluoroethylene graft was anastomosed to the BA and the EJV, and looped on the upper limb. The safety and reliability of BA-EJV access was evaluated by determining the complications, patency and intervention rates. The patient was then followed up for 20 months. The graft became thrombosed 20 months after the placement. There were no complications, such as infection, bleeding or aneurysmal lesions. Overall, the present study demonstrates that hemodialysis via BA-EJV access represents an unusual, yet effective and safe procedure, which may be conducted with acceptable complications and patency rates.

Rescue of an Axillary-Axillary Arteriovenous Graft not Amenable to Endovascular Intervention by Formation of an Axillary Loop: A Case Report

Central venous obstruction associated with a distal arteriovenous fistula can result in massive swelling of the affected extremity and venous hypertension. We present the surgical rescue of an axillary-axillary arterio-venous access ((necklace graft) between the left axillary artery to the contralateral axillary vein), compromised by central venous stenosis, by conversion into an arteriovenous axillary loop graft (AVALG) as an additional “exotic” grafting procedure in the anterior chest. This procedure resulted in the salvage of the patient's access and rapid resolution of the associated upper extremity swelling.

Early cannulation graft Flixene™ for conventional and complex hemodialysis access creation

PURPOSE

The Flixene™ (Atrium™, Hudson, NH) is a trilaminate composite polytetrafluoroethylene (PTFE) graft that allows access within 72 hours. We evaluate our initial experience with this device for conventional and complex hemodialysis access creation.

METHODS

Retrospective review in end-stage renal disease (ESRD) patients who underwent access creation with Flixene from January 2013 to July 2014. For our analysis, the patients were divided in two groups: those with complex access configurations tunneled in the chest and/or abdominal wall (thoraco-abdominal wall access [TAWA]), and those tunneled in conventional sites (extremity access [EA]). Patient's demographics, indications, complications, reinterventions, patency rates and factors influencing outcomes were evaluated.

RESULTS

In 19 patients (54% men; mean age 44 years ± 18), 24 grafts were implanted, (13 EA [54%] vs. 11 TAWA), all patent after surgery. Central venous occlusive disease (CVOD) was present in all patients with TAWA and in 7/13 (54%) EA patients (p = 0.016). Early cannulation (within 72 hours) was successful in 12 EA and 5 TAWA grafts (p = 0.044). Complication rates including infection, thrombosis, bleeding and steal syndrome were 8/11 (73%) in TAWA and 5/13 (38%) in EA (p = 0.02). At 12 months, primary patency rates for EA and TAWA were 25% and 41%; secondary patency rates were 55% and 41%, respectively.

CONCLUSIONS

Early cannulation (EC) grafts are viable alternatives for conventional and complex access creation that allowed early cannulation (<72 hours) in 17 (70%) of our cases. Primary and secondary patency rates at 12 months were equivalent to data reported on ePTFE grafts.

Extra- and intrathoracic access

The most complex patients requiring vascular access are those with bilateral central vein occlusions. Endovascular repair of the central lesions when feasible allow upper extremity use for access. When endovascular repair is not feasible, femoral vein transposition should be the next choice. When lower limb access sites have been exhausted or are contraindicated as in obese patients and in patients with peripheral arterial obstructive disease, a range of extrathoracic "exotic" extra-anatomic access procedures as the necklace cross-chest arteriovenous (AV) grafts, the ipsilateral axillo-axillary loops, the brachial-jugular AV grafts, the axillo-femoral AV grafts or even intra-thoracic ones as the right atrial AV bypasses represent the vascular surgeon's last resort. The selection among those extra-anatomical chest-wall procedures should be based upon each patient's anatomy or patient-specific factors.

Midterm experience of ipsilateral axillary-axillary arteriovenous loop graft as tertiary access for haemodialysis

Objectives. To present a series of ipsilateral axillary artery to axillary vein loop arm grafts as an alternative vascular access procedure for haemodialysis in patients with difficult access. Design. Retrospective case series. Methods. Patients who underwent an axillary loop arteriovenous graft from September 2009 to September 2012 were included. Preoperative venous imaging to exclude central venous stenosis and to image arm/axillary veins was performed. A cuffed PTFE graft was anastomosed to the distal axillary artery and axillary vein and looped on the arm. Results. 25 procedures were performed on 22 patients. Median age was 51 years, with 9 males and 13 females. Median number of previous access procedures was 3 (range 0–7). Median followup was 16.4 months (range 1–35). At 3 months and 1 year, the primary and secondary patency rates were 70% and 72% and 36% and 37%, respectively. There were 11 radiological interventions in 6 grafts including 5 angioplasties and 6 thrombectomies. There were 19 surgical procedures in 10 grafts, including thrombectomy, revision, repair for bleeding, and excision. Conclusions. Our series demonstrates that the axillary loop arm graft yields acceptable early patency rates in a complex group of patients but to maintain graft patency required high rates of surgical and radiological intervention, in particular graft thrombectomy.

Percutaneous interventions in failing "necklace" hemodialysis grafts: long-term outcomes

PURPOSE

To determine primary and secondary patency after percutaneous interventions for malfunctioning anterior chest wall ("necklace") arteriovenous grafts (AVGs) for hemodialysis.

MATERIALS AND METHODS

Records of six consecutive patients with subclavian artery-to-contralateral subclavian vein necklace AVGs were reviewed. Patients underwent 34 procedures, including 28 balloon angioplasties, 24 pharmacomechanical thrombolyses, and six stent placements. Patency intervals after graft placement and after first intervention were calculated.

RESULTS

After 3 months, primary and secondary patency rates were 33% (two of six grafts) and 67% (four of six grafts), respectively. At 12 months, primary and secondary patency rates were 17% (one of six grafts) and 50% (three of six grafts), respectively. Median and mean primary patency times were 49 and 374 days, and median and mean secondary patency times were 293 and 575 days, respectively. The anatomic success rate of percutaneous interventions in malfunctioning AVGs was 97% (33 of 34 cases). At 3 years after implantation, the graft patency rate was 57% (four of seven grafts).

CONCLUSIONS

Percutaneous interventions were effective at maintaining patency in failing necklace AVGs. However, their primary and secondary patency were inferior to those cited in extremity AVG guidelines set forth by the Society of Interventional Radiology.

Acesso vascular para hemodialise: o que ha de novo?

O aumento da expectativa de vida dos portadores de doenças crônicas, entre as quais a insuficiência renal crônica, faz com que métodos de tratamentos estejam em constante aperfeiçoamento. O uso em longo prazo da hemodiálise torna necessário confeccionar e manter acessos vasculares de utilização duradoura. Tanto as fístulas arteriovenosas - primeira opção de acesso para os pacientes hemodialíticos - como os cateteres vêm sendo objeto de estudos na literatura, na tentativa de prolongar sua vida útil. Esta revisão tem como objetivo relatar as alternativas e soluções atuais para os acessos vasculares para hemodiálise.

Percutaneous intervention in axillary loop-configured arteriovenous grafts for chronic hemodialysis patients

Objective

The purpose of this study was to evaluate the fistulographic features of malfunctioning axillary loop-configured arteriovenous grafts and the efficacy of percutaneous interventions in failed axillary loop-configured arteriovenous grafts.

Materials and Methods

Ten patients with axillary loop-configured arteriovenous grafts were referred for evaluation of graft patency or upper arm swelling. Fistulography and percutaneous intervention, including thrombolysis, percutaneous transluminal angioplasty and stent placement, were performed. Statistical analysis of the procedure success rate and the primary and secondary patency rates was done.

Results

Four patients had graft related and subclavian venous stenosis, two patients had graft related stenosis and another four patients had subclavian venous stenosis only. Sixteen sessions of interventional procedures were performed in eight patients (average: 2 sessions / patient) until the end of follow-up. An interventional procedure was not done in two patients with central venous stenosis. The overall procedure success rate was 69% (11 of 16 sessions). The post-intervention primary and secondary patency rates were 50% and 63% at three months, 38% and 63% at six months and 25% and 63% at one year, respectively.

Conclusion

Dysfunctional axillary loop-configured arteriovenous grafts almost always had subclavian venous and graft-related stenosis. Interventional treatments are helpful to overcome this and these treatments are expected to play a major role in restoring and maintaining the axillary loop-configured arteriovenous loop grafts.

Use of the internal mammary vein for access outflow in a hemodialysis fistula

A patient with occlusion of multiple central veins from both dialysis and nondialysis catheters required permanent access for hemodialysis. Magnetic resonance imaging showed a patent left innominate vein. He underwent creation of a left axillary artery to internal mammary vein transposition fistula using the basilic vein from his right arm. The fistula has required one revision for outflow stenosis and one for aneurysmal degeneration. It continues to function well 3 years after placement. The internal mammary vein is an option for outflow when permanent hemodialysis access has failed in the presence of a patent innominate vein with occluded or severely stenotic ipsilateral subclavian and jugular veins.

Asdin Original Investigation: Complex Bypasses and Fistulas for Difficult Hemodialysis Access: A Prospective, Single-Center Experience

The purpose of this article is to describe several complex vascular access procedures and the outcomes achieved with them in 24 patients (mean age 60 years) undergoing hemodialysis in whom all other accesses had failed and neither peritoneal dialysis nor transplantation was possible. Patients underwent either a necklace bypass (n = 5), axillary loop (n = 1), contralateral internal jugular vein bypass (n = 6), femorofemoral crossover bypass (n = 1), superficial femoral vein transposition (n = 5), axillary artery to popliteal vein bypass (n = 5), or femoral artery to right atrium bypass (n = 1). All grafts implanted were 6 mm, internally reinforced prostheses made of expanded polytetrafluoroethylene (Gore-Tex Intering Vascular Graft). Postoperatively patients had bimonthly clinical examinations in which the thrill, bruit, skin, cannulation sites, and adequacy of dialysis were reviewed. A bimonthly ultrasound dilution assessment that included estimation of the graft inflow rate, recirculation rate, and cardiac output was also performed. There was one serious postoperative complication: rapid-onset severe steal syndrome that required immediate tie off of the fistula. During the median follow-up time of 22 months, three patients died of causes unrelated to their vascular access. Nineteen dilatations and 10 surgical revisions were done. Primary patency rates were 83%, 63.5%, and 63.5%, respectively, at 6 months, 1 year, and 2 years; secondary patency rates were 91%, 77%, and 77%. Complex vascular access procedures can provide patients some additional good-quality time on hemodialysis.

Axillo-iliac Conduit for Haemodialysis Vascular Access

OBJECTIVES

To describe a series of venous surgical procedures performed to maintain vascular access.

METHODS

We report eight patients with end-stage renal failure (ESRF) who had complex renal access problems. Three patients had central venous occlusion and underwent veno-venous axillo-iliac bypass. In five further patients with a symptomatic central venous obstruction we performed axillo-iliac arterio-venous grafting (AVGs) in order to achieve haemodialysis access. All patients were assessed pre-operatively with duplex ultrasound and venogram of upper and lower limbs. The axillary artery or vein, and iliac vein were approached via infraclavicular and extra-peritoneal groin incisions, respectively. Non-externally-supported polytetrafluoroethylene (PTFE) was used as a conduit in all patients and anti-coagulation regimen were commenced post-operatively.

RESULTS

Following venous diversion surgery, there was a dramatic improvement in the facial and limb swelling experienced by the patients. There was no significant peri-operative morbidity. The veno-venous graft is still patent at 14 months in patient one, at 10 months in patient two, and 5 months in patient three. In the second group, who had arterio-venous grafts, the mean follow-up was 13.2 (7-20) months with a secondary patency rate of 80% at 6 months. Four patients had patent, usable grafts at 12 months. In two cases, graft occlusion was treated with successful thrombectomy.

CONCLUSION

Axillary-iliac veno-venous diversion can overcome the symptoms and complications of superior vena cava and innominate vein obstruction. Although, axillo-iliac arterio-venous graft fistulae formation was previously described it has not been widely used. We have found the procedure to have low morbidity and advocate its use in these complex cases.